The under-recognition and the under-treatment of depression in primary care is a critical public health problem with high societal costs due to disability, morbidity, mortality, and excessive health care utilization. Over the past two decades, various interventions that targeted solely primary care providers' (PCPs') recognition and management of depression have not proven effective. More comprehensive interventions that target multiple aspects of a provider's practice seem more effective than simpler ones, however, with no enduring effect. These findings suggest that the effect of interventions is not incorporated into PCPs' everyday practice. Therefore, designing effective interventions calls for an understanding of how PCPs make clinical judgments in their real-world practices and what conditions influence their everyday clinical judgment in recognizing and managing depression. This proposed R34 qualitative study is the first phase in a program of research aimed at quality improvement in the recognition and treatment of depression in the primary care setting. Ultimately, we will develop and test theory-based interventions from the perspectives of providers and patients. To provide a theoretical foundation from which to build the interventions that will endure over the long term, we first propose three specific aims: Aim l. To understand care processes by which [unreadable] PCPs recognize and manage depression in their everyday practice; Aim 2.To identify conditions (contextual factors and situations) that influence these care processes; Aim 3.To explore PCPs' experience with currently available clinical decision-making aids for depression. Using a qualitative research methodology, Grounded theory, this study utilizes 70 in-depth interviews with PCPs (general internists, family physicians, and nurse practitioners), provider surveys on psychosocial aspects of patient care, field notes on the primary care office context, and three focus groups. We aim to understand PCPs' clinical decision-making from their perspectives that are acquired from context-bound real world experiences. By using this strategy, we will take the first essential steps toward designing quality improvement interventions that are feasible and sustainable in the long-term milieu of real-world primary care practice. [unreadable] [unreadable]